A number of adverse effects associated with having a practising impaired doctor in the workplace were reported by the participants. These consequences are a cause for alarm as they have direct implications for the workplace and work performance at all levels. This finding is similar to what was reported in the literature by Merlo and Gold who concluded that ‘physician impairment is a significant issue with important public health implications’.1 In order to have a full grasp of the consequences for the impaired physician himself, his profession, his workplace and his clients, a brief look at these ramifications is essential.
5.2.1 Harm to self and family
When doctors are impaired, their conduct becomes problematic and they often exhibit disruptive unprofessional behavior inside and outside their workplaces.
Unattended, these irrational actions and behavior can progress and easily become complicated by disciplinary issues and job loss with the attendant negative financial consequences both for the ‘impaired doctor’ and his family. Reputational damage
1Merlo LJ and Gold M ‘Prescription opioid abuse and dependence among physicians: hypotheses and treatment’ (2008) 16 (3) Harvard Review of Psychiatry 181-194.
and threats of lawsuits arising from medical negligence and malpractice are real.
Criminal charges and the loss of doctor license to practice are other complications the impaired physician might have to face up to.
From the above, it is obvious that the impaired doctor is under a tremendous amount of stress that can result in him developing a major depressive illness, drug addiction problems with associated suicidal tendencies. His professional problems and personal difficulties may worsen as a significant number of colleagues are reluctant to document and refer him for appropriate professional help. 2
5.2.2 Harm to the healthcare facility
The participants identified the negative consequences of having a practicing impaired doctor in a healthcare facility. These include adverse effects on the workforce, direct negative impact on patient’s security and safety, litigations, financial loses, reputational damage, service disruptions, and reduced work output.
An important adverse effect of an impaired doctor conduct is the increased turnover rate of co-workers. Manifestation such as fear, feelings of low self-esteem, anxiety, and worthlessness are common among verbally abused healthcare professionals.3 Healthcare workers perceived the disruptive behavior of some impaired colleagues as contributing to lack of job satisfaction and dwindling moral in the workplace.
A report on a study by Cox on verbal abuse in nursing revealed an 18% turnover rate in nursing staff that is directly linked to verbal assault.4 The replacement cost of such staff members constitutes a huge financial burden for the healthcare facility.
Disruptive conducts in the impaired physician do negatively impact patients’ security and safety in the hospitals and clinics. The 2003 Institute for Safe Medication Practices (ISMP) survey report that looked into Intimidation that indicated disrespectful behaviours in the healthcare workplace, revealed that some 49% of doctors felt coerced to administer a medication even amidst unresolved serious
2Mustard LW ‘The culture of silence: disruptive and impaired physicians’ (2009) 25 (3) The Journal of medical practice management: MPM 153-155.
3 Ibid.
4Cox HC ‘Verbal Abuse in Nursing: Report of a Study: Research explores whether or not-and to what extent-verbal abuse affects nursing practice and turnover rates’ (1987) 18 (11) Nursing management 45 -50.
safety concerns, while another 40% remained quiet and did not oppose any intimidator.5 Several studies revealed that those individuals that suffered abuse in the past adopted and utilized avoidance behavior towards the intimidator in order to cope with their circumstances, notwithstanding their best intentions to improve services and care.6 Unprofessional acts in the impaired doctor have some hidden costs. Chronic absenteeism, work disruptions, late coming to work and sick leave abuse tend to result in low morale in the workforce. This tends to create an administrative nightmare leading to reduced productivity. Wastage of material resources and a rise in the occurrence of medical errors with the associated medico- legal consequences and litigations do contribute to the financial consequences and reputational damage the healthcare facility may suffer. Indeed, the ‘Joint Commission on Accreditation of Healthcare Organization (JCAHO)’ viewed and linked these unprofessional actions and behavior to patients dissatisfaction with the care received, medical mistakes, negative outcomes and escalated costs resulting from wastages and staff turnover.7
5.2.3 Harm to the medical profession
Every medical doctor registered with the HPCSA is expected to uphold the goals of professionalism. This include amongst others, a dedication to provide high-quality medical care and maintenance of a high standard of professionalism.8 Impairment in these doctors negate their capacity to maintain professionalism and offer competent care to their clients. The participants noted that impaired physician’s actions and conduct do lead to ‘dishonourable conduct’.9
Unprofessional conduct that includes taking advantage of patients or their relatives, indulging in a sexual relationship with patients or breaching patient confidentiality as
5 Institute for Safe Medication Practices (2003) survey on workplace intimidation Available at, https://www.ismp.org/Survey/surveyresults/Survey0311.asp (Accessed: 15 Sep 2017).
6Rosenstein AH and Michelle O'Daniel ‘Disruptive Behavior and Clinical Outcomes' (2005) 36 (1) Nursing Management 18 -28.
7Ibid.
8National Health Act 61 of 2003.
9ibid
in De Beer v HPCSA 2005 (1) SA 332(T)10, may lead to the doctor being disciplined by the HPCSA for bringing the medical profession to disrepute.
5.2.4 Harm to the patient
Participants positively identified the existence of the potential for harm to the patient during an impaired doctor-patient interactions or consultation process.
Unprofessional behavior and conduct by the impaired doctor do generate a sense of insecurity and fear in the patients of the impaired doctor. The patient’s right to security and safety as guaranteed by the Constitution11 is undermined and their trust in the health establishment and the multidisciplinary healthcare team is guaranteed to plummet. Outright physical and emotional abuse of patient leading to anger, frustration and general dissatisfaction with medical care can occur. Patients experience delayed access to care arising from the impaired physician’s absenteeism, late coming to work, inappropriate and unproductive arguments with colleagues, nursing staff, and the patients.
The medical profession has an ethical obligation to inflict no harm on anyone.12 This is completely encapsulated in 'the maxim, primum non nocere, first does no harm'.13 When a doctor becomes impaired, the main issue that arises in terms of nonmaleficence is the protection of the clients from the impaired medical practitioner.
This is because impaired doctors can cause harm to their clients. Therefore, all policies dealing with impairment in doctors should incorporate aspect that deals with prevention of impaired doctor induced injury to his/her clients.
10In the De Beer case. The appellant was a Medical Practitioner registered with the HPCSA. He appealed in the Pretoria High court against the removal of his name from the register of doctors. This comes after a series of allegations of professional misconduct one of which was sexual in nature. The appeal was subsequently dismissed.
11Constitution of South Africa s24a.
12Beauchamp TL and Childress JF Principles of Biomedical Ethics Oxford University Press USA (2001) 114-119.
13Ibid.
5.3 Physician Impairment: A major unaddressed issue